As an
acupuncturist, one of the most common questions that I get asked is “Does
acupuncture really work?” And, drawing on my own clinical experience and the
thousands of years of other acupuncturists’ clinical experiences before me, I
can confidently answer “yes, yes it does work.” However, in today’s modern
scientific world, many people (including most doctors), want to see the
evidence. This is a completely understandable desire and a very worthwhile
inquiry into the art of acupuncture. However, the problem comes from how we
define evidence. While I believe that there is an abundance of evidence that
acupuncture works - from clinical experience, from ancient texts, from
observational studies, and even from some well-designed controlled trials of
acupuncture - the dominant medical system understands the effectiveness of a
medical intervention almost solely through its effects in randomized controlled
clinical trials.  Randomized
controlled clinical trials were designed to test pharmaceutical drugs and
control for patient expectations during the trial. Hence, the model evolved
that one group of patients would be randomly assigned to receive the active
drug, and one group would be randomly assigned to receive a placebo sugar pill,
and no patients would know which treatment they were receiving.For the
past many decades, researchers have tried to figure out how to test acupuncture
in a clinical trial in the same manner. Like regulating the dose and method of administration in a
pharmaceutical trial, they regulated each aspect of the acupuncture treatment –
which points the acupuncturist would needle (which would be the same for each
patient), how deep the needle would be, how much stimulation the acupuncturist
would use. And like giving some patients a sugar pill in a drug trial,
researchers designed “sham acupuncture” as a control group – either not
inserting the needle (but rather touching the skin), or needling superficially,
or needing non-acupuncture points. While a few very successful studies did show
a difference between real and sham acupuncture, the vast majority of these
studies had similar results, for everything from back pain to arthritis to
headaches: BOTH real and sham acupuncture groups improved significantly more
than a usual-care group, but real acupuncture did not perform significantly
better than the sham acupuncture. This led – and still leads – scientists to
conclude that acupuncture is “only a placebo” treatment, and that it isn’t
actually an effective treatment. Now,
there are numerous problems with this design, and with the conclusions that are
drawn from it. Traditional Chinese medicine is a complete medical system that
has been used successfully for thousands of years. It has a very different way
of looking at the body, different terminology, a different way of explaining
why things happen. It is holistic.  Think
of it like a circle. Biomedicine, on the other hand…think of it like a square.
The randomized controlled trial, we often forget, is PART OF THE BIOMEDICAL
SYSTEM. It was created based on a biomedical view of the body, and it is
utilized based on biomedical principles. The whole point of a biomedical
randomized controlled trial is to isolate and test the active ingredient in the
intervention (ie, the drug)…but this whole notion is based on the understanding
that there is a single active component to the intervention that is responsible
for the healing. Which is not how Chinese medicine views the body, or the
world, at all. Trying to prove that acupuncture is effective using a randomized
controlled trial is like trying to fit a circular peg into a square hole…and
then when it doesn’t fit, concluding that the circle is ineffective and wrong. Problems with Sham
Acupuncture Sham
acupuncture, as I said, is meant to mimic a placebo pill in a drug trial. This
means that it is supposed to be ineffective. However, we do not yet know…from a
biomedical standpoint…why acupuncture works. (We do know why acupuncture works.
However, our understanding of acupuncture is based on acupuncture theory. We
speak of yin and yang, qi and blood (see our earlier blog post on TCM theory).
We don’t yet know, definitively, why acupuncture works from a biomedical perspective.) There are many promising theories
that have proved viable in small pilot studies, such as that acupuncture may
regulate the endocrine system, activate the peripheral nervous system, act
directly on the brain and central nervous system, correspond to changes in the
fascia of the musculoskeletal system, influence electromagnetic pathways,
activate neurotransmitters, and more. However, we do not know why acupuncture
works in the way that we know why a certain test drug is supposed to work. And
if we don’t know what the active component of the acupuncture treatment is, how
are we supposed to know how to design an inactive
sham acupuncture intervention? Some sham
interventions, as I mentioned, do not actually insert the needle, but rather
just touch the point of the needle to the skin. However, there are
non-insertive styles of acupuncture, such as the Japanese practice of Shakuju
therapy, the use of magnets, or acupressure. These are understood clinically to
be active interventions. Yet they are used as a control in some acupuncture
studies. Other sham interventions needle the body, but only superficially,
whereas the true acupuncture group receives much deeper needling. Yet again,
there are schools of acupuncture that only use superficial insertions. Most
styles of Japanese acupuncture fall into this category. Still other sham
interventions use acupuncture needles inserted on acupuncture points off of the
understood meridians. From the
perspective of an acupuncturist, this one is harder to understand. However, it
is true that acupuncture points are located in slightly different locations
based on the school of acupuncture. There are hundreds of “extra” and empirical
points that are not located on the main meridians. Perhaps
most importantly, the whole concept of a sham intervention relies on the belief
that what makes acupuncture “acupuncture” is the actual insertion of the
needles into the body. However, I think that any acupuncturist will tell you
that inserting needles into the body is only one part of the treatment. Acupuncture
is based on energy. We call it “qi” in Chinese medicine. Acupuncture is an
energetic treatment, and as such, we are dealing with energy. When I insert a
needle into a patient, I stimulate the needle until I feel the patient’s energy
wrap around the needle inside. However, this is not accounted for in a clinical
trial. We don’t know how to measure qi, we don’t know what it translates to in
Western medicine, and so we don’t know how to design a study that takes it into
account. Problems with Acupuncture
Interventions in clinical trials  While
this is slowly changing as our research community becomes more enlightened to
the issues surrounding acupuncture research, the vast majority of research
studies in the past have required that the acupuncturist perform a set protocol
of points on their patients. However, this is never how an acupuncturist would
practice in the real world. Every patient that comes in with a headache is not
treated the same way. Your headache could be due to a deficiency of a certain
energy, or too much of a different kind of energy, or the energy could be
stuck. Your treatment would be very different based on the Chinese medical
reason for the headache. Additionally, your treatment would be different based
on your age, your condition, other presenting health factors, your diet, the
time of year, the time of your cycle if you are female. So using a standardized
protocol vastly limits what the acupuncturist can do. In reality, research
studies designed this way are not testing acupuncture, as they claim, but
rather they are testing that one specific protocol, which was most likely
invented for the purpose of the study.Looking forward Luckily,
researchers are starting to pay attention to all of these important points.
Even funding agencies, such as the National Institute of Health and the
Department of Defense, are starting to understand that perhaps a new model of
testing acupuncture needs to be given a chance. Acupuncture research, most
importantly, must allow the acupuncture to maintain its integrity as a
powerful, holistic, individualized intervention, because otherwise what is
being tested is not acupuncture. And many of these effectiveness studies that
do allow acupuncture to be performed in a less fabricated way show amazing
results. So be a discerning reader when
you come across a medical study on acupuncture, and remember that a circle
should be measured as a circle…not as something that it is not. |
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